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PCCN Review - Pulmonary Exam
Questions and Answers
Your patient had an exacerbation of COPD. The rapid response team was called and is currently intubating the patient and preparing him for transfer to ICU. When the family visits, they are shocked to see the people working with the patient. No one had told them the patient had deteriorated and required intubation. After the patient is intubated and is being wheeled past them, family members try to communicate verbally with the patient, but he does not respond except to gesture. The nurse should tell the family members: -They must leave the area because they are exciting the patient. -The tube used for breathing prevents the patient from speaking -They must speak with the doctor, who will explain why the patient cannot speak -The patient is very ill and may die. - answer The tube used for breathing prevents the patient from speaking This is a case where communication is clearly the problem. The family should have been informed by someone that the patient needed assistance with breathing and that they should expect a transfer. It should also have been mentioned how the patient might look in the ICU. In addition, it could have been communicated about the patient's inability to speak. The other answers are all non-theraputic responses. The family is clearly distressed, so a simple explaination in best. Ben was just transferred to the PCU. He had been in ICU for 2 weeks. Ben was intubated for a time because of his ARDs. On arrival to your unit, you note that he is tachycardic and restless. Ben states, "I can't be here now. What if something like this happens to me again?" The nurse's best response would be: -The nurses in our unit can take care of you -We are not very far away at the nurses' station -Your insurance will not cover another day there -You sound concerned about leaving the ICU - answer You sound concerned about leaving the ICU Theraputic communication occurs when the patient's feelings are validated. This response allows for the patient to express the concerns he has about the transfer. The other answers are closed and judgmental and do not allow for any expression of feeling from the patient.
Ben was just transferred to the PCU. He had been in ICU for 2 weeks. Ben was intubated for a time because of his ARDs. On arrival to your unit, you note that he is tachycardic and restless. A set of blood gases drawn just prior to his transfer show: pH 7.52, PaCO2 31, HCO3 22, PaO2 87. These results would indicate: -Respiratory acidosis -Respiratory alkalosis -Metabloic acidosis -Metabolic alkalosis - answer Respiratory alkalosis Ben was quite anxious and tachycardic. His RR probably was increased because of both anxiety and his condition. He would blow off CO2. His pH is below normal, so it is uncompensated. The HCO3 is low, indicating alkalosis The interpretation would be: Uncompensated Respiratory Alkolosis Ben was just transferred to the PCU. He had been in ICU for 2 weeks. Ben was intubated for a time because of his ARDs. On arrival to your unit, you note that he is tachycardic and restless. Ben is finally released from the hospital. He plans to visit his family in Denver. Part of the patient teaching for Ben should include information on the effects of high altitude on his ability to oxygenate effectively. Which of the following changes would be expected on his blood gas results? -The pH would decrease -No effect -The O2 saturation would decrease -The PaO2 would increase - answer The O2 saturation would decrease At higher altitudes, there is decreased atmospheric pressure to force oxygen into the lungs. To compensate for the lower pressure, the person must breathe faster. The percentage of oxygen remains the same, but the partial pressure of the oxygen decreases. Aterial PaO2 decreases, as does O2 saturation. The rapid breathing will result in hyperventillation, raising the pH and lowering the PaCO2 level. SaO2 values account for what % of O2 carreid within the bloodstream? -2-3% -10-24% -97-98%
-Surfactant -CO2 - answer Surfactant Surfactant is a lipoprotein that functions by increasing surface tension of alveoli and allow alveoli to expand and contract. Some residual pressure should be present in the alveoli at the end of respiration to keep the alveoli open (physiologic PEEP). If surfactant production is impaired, the alveoli's ability to exchange O2 is compromised. Type I cells line the outside of the alveoli. If you hear faint breath sounds on the left side of the chest and normal sounds on the right side immediately after your patient is intubated, most likely: -The patient has a tumor -The doctor has intubated the esophagus -The ET is at the carina -The right mainstem has been intubated - answer The right mainstem has been intubated The right mainstem bronchus is somewhat wider and has less of an angle off the mainstem bronchus, so it is much more readily intubated. John is a 32 year old engineer that has been on hemodialysis for 3 years. He missed his last 2 treatments. He is lethargic, lacks stamina, and is very edematous. His ABGs show: pH 7.30, PaCO2 32, HCO3 17, PaO2, 90. John's results indicate: -Metabolic alkalosis -Respiratory acidosis -Metabolic acidosis -Respiratory alkalosis - answer Metabolic acidosis More specifically, this ABG indicates an Uncompensated Metabolic Acidosis. The pH is low, as is the PaCO2. You ask a fellow nurse to carry a newly drawn ABG specimen to the lab. She does not plave the sample on ice. What effect will the lack of icing have on the sample: -None -It will invalidate the sample -The pH will rise -The PaCO2 will rise - answer It will invalidate the sample The PaCO2 will rise approximately 3-10 mmHg per hour.
The PaO2 and the pH will decrease. Your patient must have an ABG. The respiratory therapist says he is out of prepared syringes, so he obtains a syringe into which he places heparin. What effect will too much heparin have on the sample, if any? -Decreased bicarbonate -No effect -Increased PaCO -Totally prevent clotting - answer Decreased bicarbonate The heparin will have dilutional effects and will decrease the bicorbonate level and the PaCO2. While the RT is attempting to draw an ABG, you note that he is exerting a lot of force to more the cylinder of the syringe. What effect will this high-friction syringe have on the ABG results, if any? -It will put the artery into spasm -Increase the PaCO -Decrease the PaO -No effect on the results - answer Decrease the PaO Using a vacutainer or a high-friction syringe will create a vacuum. When that occurs, dissolved gases come out of solution, which decreases PaO2 and PaCO2. The increased effort required to move the cylinder may cause the artery to spasm and make it more difficult to obtain the sample, but will not directly affect the results The RT asks if the patient has a fever. The possibility of fever will have what effect on the sample: -The HCO3 will be elevated -The PaCO2 will rise -Fever has no effect -The pH will rise - answer The pH will rise Most ABG machines are calibrated to 37'C. If the patient has a fever, the oxyhemoglobin curve will be shifted to the right. More oxygen will be given off to the tissues, so the machine has to be calibrated to account for the higher temperature. Familial emphysema is a condition that results in a deficiency in: -Adenosine monophosphate -Ability to produce mucus -Alveoli -Serum alpha-antitrypsin - answer Serum alpha-antitrypsin
Today, Sherie was working in her garden when she found that she could not catch her breath. Her bronchospasms worsened, and she was transported to the ED. In the ED, she recieved albuterol, oxygen, and epinephrine without significant improvement. On auscultation, inspiratory and expiratory wheezing with a prolonged expiratory phase is heard throughout the lung fields. Sherie is using accessory muscles for respiration and is tachycardia and tachypneic. She is placed on O2 at 2 L/min via NC and ABGs are drawn. Blood gas results are: pH 7.52, PaO2 106 mmHg, PaCO2 27 mmHg, HCO3 24 mEq/L. The doctor now orders Inderal (propanolol). As a nurse, you know that propanolol is contraindicated for asthmatics because: -It will exacerbate the tachycardia -It will lead to a severe respiratory acidosis -PNA may result -Bronchospasm may worsen - answer Bronchospasm may worsen Propanolol may cause bronchospasm. It works by blocking beta-adrenergic effects of the sympathetic nervous system (like bronchodiation). Some beta blockers are cardioselective (e.g. atenolol), and newer agents such as nebivolol, provide for cardioselective beta blockade with vasodilation. Sherie is a 20 year old admitted to your PCU with status asthmaticus. She has been taking Accolate, Allegra, and has been using a Proventil HFA rescue inhaler at home. Today, Sherie was working in her garden when she found that she could not catch her breath. Her bronchospasms worsened, and she was transported to the ED. In the ED, she recieved albuterol, oxygen, and epinephrine without significant improvement. On auscultation, inspiratory and expiratory wheezing with a prolonged expiratory phase is heard throughout the lung fields. Sherie is using accessory muscles for respiration and is tachycardia and tachypneic. She is placed on O2 at 2 L/min via NC and ABGs are drawn. Blood gas results are: pH 7.52, PaO2 106 mmHg, PaCO2 27 mmHg, HCO3 24 mEq/L. The most probably cause of Sherie's acid-base imbalance would be: -An adverse effect of albuterol -A side effect of theophylline -Hyperventilation -Hypoventilation - answer Hyperventilation Sherie is probably very anxious and hyperventilating because she is unable to get enough oxygen due to bronchial constriction. Hypoventilation causes a buildup of CO2, leading to respiratory acidosis. This patient has not received theophylline and Albuterol may cause tachycardia, but not an acid-base imbalance. Sherie is a 20 year old admitted to your PCU with status asthmaticus. She has been taking Accolate, Allegra, and has been using a Proventil HFA rescue inhaler at home. Today, Sherie was working in her garden when she found that she could not catch her breath. Her bronchospasms worsened, and she was transported to the ED. In the ED,
she recieved albuterol, oxygen, and epinephrine without significant improvement. On auscultation, inspiratory and expiratory wheezing with a prolonged expiratory phase is heard throughout the lung fields. Sherie is using accessory muscles for respiration and is tachycardia and tachypneic. She is placed on O2 at 2 L/min via NC and ABGs are drawn. Blood gas results are: pH 7.52, PaO2 106 mmHg, PaCO2 27 mmHg, HCO3 24 mEq/L. Sherie's O2 was increased to 5 L/min via mask. On auscultation, you note that the wheezing is barely audible. This finding may indicate: -Improvement -Need to lower O -A need for epinephrine -A worsening condition - answer A worsening condition It is unlikely that Sherie's condition is improving. The air becomes trapped in the alveoli and excessive mucus is produced. The patient struggles to breathe and may become exhausted. When the wheezing diminishes or stops altogether, it means air is not able to pass through an opening. This is a medical emergency, and the patient may need to be intubated. A lot of controversy surrounds the issue of intubation asthmatics, because this procedure may cause barotrauma, hyperinflation, and cardiac compromise. A possible treatment to best improve airflow in status asthmaticus is: -Bromex
- Heliox -Norepinephrine -Nebulizer treatments - answer Heliox Heliox is a helium-oxygen mixture that can help with the delivery of inhaled medications, thereby decreasing the work of breathing. Norepinephrine is a vasocontrictor. Nebulizers may also work, but if the patient's condition is compromised the effectiveness is minimal at best. Sherie is a 20 year old admitted to your PCU with status asthmaticus. She has been taking Accolate, Allegra, and has been using a Proventil HFA rescue inhaler at home. Today, Sherie was working in her garden when she found that she could not catch her breath. Her bronchospasms worsened, and she was transported to the ED. In the ED, she recieved albuterol, oxygen, and epinephrine without significant improvement. On auscultation, inspiratory and expiratory wheezing with a prolonged expiratory phase is heard throughout the lung fields. Sherie is using accessory muscles for respiration and is tachycardia and tachypneic. She is placed on O2 at 2 L/min via NC and ABGs are drawn. Blood gas results are: pH 7.52, PaO2 106 mmHg, PaCO2 27 mmHg, HCO3 24 mEq/L. Sherie's O2 was increased to 5 L/min via mask. Sherie now needs immediate intubation and is placed on mechanical ventilation, and then transferred to the ICU. The
-Atelectasis -Pneumothorax -Sepsis - answer Atelectasis Three days of high FiO2 has resulted in a nitrogen washout, resulting in atelectasis. Nitrogen's high partial pressure is necessary to maintain alveolar inflation. It is important to titrate FiO2 to maintain O2 saturation within a prescribed range when O2 therapy is utilized. Pulmonary edema would result in coarse breath sounds. With unilateral pneumothorax, tracheal deviation might be observed. Sepsis would not necessarily present with diminished breath sounds, but additional findings could include increased purulent secretions, coarse breath sounds, and altered lab results. As patients age, chest wall compliance decreases. One of the reasons for this change is that: -Total lung capacity decreases -Costal cartilage degenerates -Arterial oxygen tension increases -Residual volume decreases - answer Costal cartilage degenerates Sometimes the costal cartilage becomes calcified with age. Vertebrae develop osteoporosis, and a degree of kyphosis can occur. Weight gain is common and posture is affected. The chest wall compliance decreases, as does vital capacity. Residual volume increases, PaO2 decreases, and PaCO2 increases. The cells that are responsible for forming a barrier for alveoli are: -Macrophages -Type II alveolar epithelial cells -Type I alveolar epithelial cells -Cilia - answer Type I alveolar epithelial cells Type I cells line the outside of the alveoli. These cells, which maintain the blood-gas interface, are easily inflamed by inhaled toxins or heated air. Type II cells produce surfactant. Anatomic dead space isreferred to as: -Minute ventilation -Wasted ventilation -Physiologic dead space -Conducting airways - answer Conducting airways
Conducting airways are ventilated, but perfusion (gas exchange) does not occur. Wasted ventilation is the amount of ventilation that does not participate in gas exchange. The oxyhemoglobin dissociation curve is: -A graphic representation showing the relationship between dissolving oxygen and the affinity for oxygen by the hemoglobin molecule -A graphic representation of carbon dioxide content verses oxygen content in arterial blood -A measure of methemoglobin -A way to calculate gas transport across the alveoli - answer A graphic representation showing the relationship between dissolving oxygen and the affinity for oxygen by the hemoglobin molecule The oxyhemoglobin dissociation curve reflects physiological circumstances and their effect on the hemoglobin's affinity for oxygen. If the oxyhemoglobin curve shifts to the right, one factor that will affect this shift is: -A decreased CO -A decreased pH -A decrease in temperature -A decrease in 2,3-DPG - answer A decreased pH A shift to the right means hemoglobin has less affinity for oxygen. 2,3-Diphosphoglyceride (2,3-DPG) is needed to help force O2 off the hemoglobin molecule. If 2,3-DPG levels decrease, the hemoglobin will hang onto O2. If the temperature increases, the tissues need more O2. If the PCO2 becomes elevated, the tissues need more O2. If the oxyhemoglobin dissociation curve shifts to the left, which of the following would precipitate this change? -Increased temperature -Increased PaCO -Increased 2,3-DPG -Increased pH - answer Increased pH When the oxyhemoglobin dissociation curve shifts to the left, it means that hemoglobin holds onto oxygen.
pH 7. PO2 93 mm Hg PaCO2 52 mm Hg HCO3 23 mEq/L -Uncompensated respiratory acidosis -Compensated metabolic acidosis -Uncompensated metabolic alkalosis -Compensated respiratory acidosis - answer Uncompensated respiratory acidosis The pH shows that the patient's condition is uncompensated and acdotic (<7.35), the elevated CO₂ indicates that the condition is respiratory (>45 mm Hg), and the bicarbonate is normal (22-26 mm Hg). Hence the patient has uncompensated respiratory acidosis. Your patient had 1250 ml of pleural effusion removed via thoracentesis and immediately began coughing and was dyspneic. You believe he has developed: -A pneumothorax -Reexpansion pulmonary edema -Cardiac tamponade -Hemothorax - answer Reexpansion pulmonary edema Removal of large amounts of pleural fluid (greater than 1000 ml) increases negative intrapleural pressure. Edema occurs when the lung does not reexpand. The patient develops a severe cough and dyspnea. If these symptoms occur during thoracentesis, the procedure should be stopped. Falsely low readings on a pulse oximeter may be due to : -Electronic interference from hemodialysis -Fever -Vascular dyes -Polycythemia - answer Vascular dyes Certain dyes interfere with the sensor's ability to conduct red and infrared light. These dyes include methylene blue, fluroscein, indocyanine green, and indigo carmine. Joseph's tracheostomy tube cuff has been requiring increasing pressures all shift to maintain a good air seal. What is a possible complication? -Tracheal stenosis -Air embolus -Tracheal atrsia -Erosion of the innominate artery - answer Erosion of the innominate artery
Erosion of the innominate artery is probably when the tip of the tube rubs agaist tissue or the stoma is too low. The trachea is somewhat oval, whereas the tube and cuff are circular. THe tube may have been loose and allowed for more than the usual movement of the tube. A contraindication for use of a nasal trumpet would include: -Use as an alternative to oral intubation -Basilar skull fracture -Use with unconscious patients -A situation in which the nasal trumpet might be easily dislodged - answer Basilar skull fracture The nasopharyngeal airway should not be used on patients with basial skull fractures, sepsis, bleeding disorders, malformations or injuries to the nares, or nasal obstructions. Use this type of airway with caution in patients who arereceiving anticoagulants, fibrinolytics, or thrombolytics. The RT tells you he is covering another unit and cannot perform postural drainage on your patient. He says your patient needs the left upper lobes drained if possible. The correct position to help this patient is: -Semi-reclining -Flat with hips elevated -Supine -Flat on left side - answer Semi-reclining A semi-reclining or upright position will promote upper lobe drainage. Fluid or secretions will collection if the patient is positioned flat. The RT has just given your patient an aerosol treatment. Which of the following conditions is contraindicated for this treatment: -Pleural effusions -Head injury -Asthma -Stridor - answer Head injury If the head is lower than the body intracranial pressure is increased. It is also best to avoid postural drainage in a woman in the last 2 to 3 month of pregnancy, because the baby will shift towards the lungs and may cause respiratory distress. It is also a good idea to wait an hour after the patient eats before giving an aerosol treatment so as to avoid nausea, vomiting, and possible aspiration. BiPAP is somewhat useful in acute respiratory distress syndrome (ARDS) because:
The lungs are susceptible to collapse (pneumothorax). Barotrauma may also damage major blood vessels. Signs and symptoms of a pulmonary embolus can include: -A normal EKG or sinus bradycardia -Pleuritic chest pain and decreased cardiac output -ABGs showing respiratory acidosis and increased respiratory rate -Decreased pulmonary pressures. - answer Pleuritic chest pain and decreased cardiac output An acute pulmonary embolism can be associated with right heart failure. The patient may have chest pain, dyspnea, tachycardia, hypotension, shock and possibly coma. Your patient is undergoing a cardiopulmonary arrest. The patient is being ventilated with a BVM device and oropharyngeal airway is in place. A continuous end-tidal CO₂ (PET CO₂) device is built into the BVM. The doctor suspects the patient has suffered a pulmonary embolism. An expected change in parameters would include: -Increased PaO₂ -Decreased CVP -Decreased PET CO₂ -Increased PaCO₂ - answer Decreased PET CO₂ The patient will have a sudden decrease in the PET CO₂ due to loss of blood flow in the pulmonary vasculature. The decrease in blood flow increases dead space, with a resultant decrease of the PET CO₂ On an EKG, an extensive pulmonary embolism may show: -Tall, peaked T waves in leads II, III and AVF -Sinus bradycardia -Inverted T waves in leads V6-V -Complete heart block - answer Tall, peaked T waves in leads II, III and AVF In addition, in pulmonary embolism, the EKG may actually be normal, may show right axis deviation, T-wave inversion (leads V1-V4) amd ST-segments depression. New- onset atrial fibrillation and RBBB may also occur. Hannah was admitted to the ICU with a fever of 102.3'F, headache, dyspnea, dry cough, and chills. Her lab results indicated a low while blood count, low platelets, and raised C-reactive protein. Hannah's history includes a recent trip to a remote Chinese village within the past 2 weeks. You suspect Hannah may have: -PNA -SARS
-Influenza -Pericarditis - answer SARS Severe acute respiratory syndrome (SARS) is a community acquired PNA. Its incubation period is usually 2-14 days, and the pathogen -- SARS associated coronavirus -- is spread via droplets. SARS is usually acquired in underdeveloped areas. THere is no cure and symptoms are treated as they appear. It is incumbent on the nurse to make certain that the patient is placed in a negative pressure isolation room and that an N-95 respirator mask is used. Which of the following statements is true about a pulmonary embolism? -Respiratory acidosis will occur -Heparin is used to dissolve clots -Normal D-dimer results can rule out a pulmonary embolism -Metabloic alkalosis will develop - answer Normal D-dimer results can rule out a pulmonary embolism If the D-dimer is elevated it may be caused by multiple other conditions. A normal D- dimer rules out a pulmonary embolism. Hyperventilation will occur subsequent to hypoxemia, so respiratory alkalosis will occur. Heparin does not dissolve existing clots. Gail was admitted to the PCU following a fall from a stepstool. She complains of stabbing substernal pain each time she changes her position. Gail has been diagnosed with pneumomediastinum. A common significant finding with this diagnosis is: -Cullen's sign -Grey-Turner's sign -Hamman's sign -Handes' sign - answer Hamman's sign Hamman's sign is a "crunching" sound or a slight clicking sound with each heart sound, auscultated over the apex of the heart. Severe carbon monoxide poisoning occurs with carboxyhemoglobin levels are higher than which of the following percentages? -10-15% -20-40% -40-50% -50-60% - answer 20-40%
-The patient must have an absent gag reflex -A laryngeal mask airway eliminates the risk of aspiration - answer The patient must have an absent gag reflex The patient must have an absent gag reflex. The laryngeal mask airway (LMA) cannot be inserted by nurses unless they have received specialized training. The LMA does not usually cause hoarseness because it does not pass through the vocal cords. There is a high risk of aspiration with use of the LMA. Which of the following drugs would be considered a mucolytic agent? -Atropine -Terbutaline -Acetyl-cysteine -Albuterol - answer Acetyl-cysteine Acetyl-cysteine contains a sulfide group that effectively splits disulfide bonds in mucin molecules, thereby reducing the viscosity of the mucus. Atropine is an anticholinergic. Terbutaline and albuterol are B₂-agonists. Side effects of aceytl-cysteine include: -Bronchospasm -Headache -Hypertension -Red urine - answer Bronchospasm Thinning mucus may promote excessive coughing with resultant bronchospasm. Additional side effects include rhinorrhea, stomatitis, nausea, and vomiting. One of the most effective ways to relieve bronchospams is to administer: -Adrenalin -An antihistamine -Prednisone -A Beta₂-receptor agonist - answer A Beta₂-receptor agonist Beta₂-receptor agonist lowers cellular calcium levels and relaxes bronchial smooth mucles. Selective B₂-receptor agonists do not produce cardiac stimulation. The cardiac stimulation can result in tachycardia and reduced cardiac output. Which of the following drugs is a methylzanthine? -Prenisone
-Theophylline -Atropine -Accolate - answer Theophylline Methylzanthines, which include caffeine and theobromine, are in important class of drugs. They can be found in coffee, tea and cocoa. This class of drugs, when given in low doses, stimulates cortical arousal. In higher doses, they cause insomnia. Methylzanthines can cause tachycardia, increased production of gastric acid and digestive enzymes, and inhibit histimine release. To determine whether your patient has a genetic predisposition for malignant hyperthermia, which of the following drugs might be used: -Holothane -Caffeine -Accolate -Singulair - answer Caffeine In malignant hyperthermia, the use of anesthetic agents such as holothane cause muscles to contract and the patient to become hypothermic. Caffeine is used diagnostically in such cases because, when given at high doses, it can contract muscles without the danger of depolarizing cell membranes. The antidote for malignant hyperthermia is dantrolene. During a cardiac arrest, your patient aspirated gastric contents. Which of the following statements is true regarding this type of aspiration: -If the pH of the material is <2.5, necrosis will be minimal -The patient will always develop ARDS --There is little danger of atelectasis - answer Onset of symptoms usually occurs gradually Symptoms have gradual onset. The patient may develop ARDS, but not always. If the pH is >2.5, very little necrosis will occur. If the pH is <2.5, there is probability of pulmonary edema, necrosis, bleeding and atelectasis. Devin was admitted from abrupt-onset fever, chills, vomiting, diarrhea, and headache that developed in the past 24 hours. Devin recently had been on a cruise to Barbados. Devin is probably suffering from: -A Pseudomonas infection -Influenza -A Klebsiella infection -Legionnaire's disease - answer Legionnaire's disease
